COVID-19 Patient Disclosure

COVID-19 Patient Disclosure

Following CDC guidelines during this pandemic, this patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus. A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us. It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.

    * Required information

    Do you have a fever or above normal temperature?* YesNo

    Have you experienced shortness of breath or had trouble breathing?* YesNo

    Do you have a dry cough?* YesNo

    Do you have a runny nose?* YesNo

    Have you recently lost or had a reduction in your sense of smell?*YesNo

    Do you have a sore throat?* YesNo

    Have you been in contact with someone who has tested positive for COVID‐19?* YesNo

    Have you been tested for COVID‐19 and are waiting results?* YesNo

    Have you tested positive for COVID‐19?* YesNo

    Have you traveled outside United States by air or cruise ship in the past 14 days? YesNo

    Have you traveled within United States by air, bus or train within the past 14 days?* YesNo

    First Name*:

    Last Name*:


    I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.
    By signing this document, I acknowledge that the answers I have provided above are true and accurate.

    Use your finger on mobile device or the mouse on laptops to sign this form before clicking submit